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Somatosensory stimulation interventions for children with autism:

Literature review and clinical considerations


doi:10.2182/cjot.07.013 This paper was published in the CJOT Early Electronic Edition, Fall 2007.

Sandra Hodgetts

William Hodgetts

Key words

Occupational therapy practice

Autism

Sensory stimulation

Mots cls

Pratique de l'ergothrapie

Autisme

Stimulation sensorielle

Abstract
Background. There is considerable evidence that children with autism experience sensory dysfunction, which can affect their
ability to participate in functional activities. Occupational therapists frequently recommend somatosensory stimulation
interventions to mitigate sensory dysfunction and improve a child's ability to function. Purpose. This paper examines the
rationale and evidence supporting somatosensory stimulation interventions for children with autism. Method. A comprehensive
review of the literature specific to somatosensory stimulation was conducted, resulting in six published studies that addressed
interventions feasible within a child's daily routine. Discussion. Although research related to somatosensory stimulation
interventions is becoming more rigorous, empirical support remains limited; therefore, when these interventions are implemented,
they should be systematically evaluated. Practice Implications. To help occupational therapists recommend interventions with
confidence, strategies are provided to (1) utilise best practices to intervene in an area in which evidence is limited, and (2) help
expand the evidence base through clinical research.

Rsum
Description. Il existe beaucoup de donnes permettant d'affirmer que les enfants atteints d'autisme ont des dficits sensoriels
pouvant avoir des effets sur leur capacit de participer des activits fonctionnelles. Les ergothrapeutes recommandent
frquemment des interventions bases sur la stimulation somatosensorielle afin d'attnuer les dficits sensoriels et d'amliorer les
capacits fonctionnelles de l'enfant. But. Cet article examine la raison d'tre et les donnes probantes qui soutiennent les
interventions bases sur la stimulation somatosensorielle auprs des enfants atteints d'autisme. Mthodologie. Une revue
complte de la littrature portant spcifiquement sur la stimulation somatosensorielle a t effectue. Cette recension a permis de
reprer six tudes publies portant sur les interventions qui peuvent s'insrer dans la routine quotidienne de l'enfant. Discussion.
Bien que la recherche associe la stimulation somatosensorielle soit devenue plus rigoureuse, les donnes empiriques demeurent
limites; ainsi, il est important, lorsque ces interventions sont mises en uvre, de les valuer systmatiquement. Consquences
pour la pratique. Afin d'aider les ergothrapeutes recommander des interventions en toute confiance, les auteurs proposent des
stratgies visant (1) utiliser des pratiques exemplaires pour intervenir dans un domaine o les donnes probantes sont limites
et (2) produire davantage de donnes probantes l'aide de la recherche clinique.

n the past decade, the treatment of autism has garnered


increasing attention across North America, escalating the
demand for empirically supported treatments and interventions (Rogers, 1998). Autism is now the most common
neurodevelopmental diagnosis affecting children with as
many as 1 in 166 children receiving a diagnosis along the
spectrum (Fombonne, 2003). Accordingly, the number of
children with autism on occupational therapists' caseloads
increased during the last decade (Case-Smith & Miller, 1999).
Given the current prevalence of autism, it is fair to expect
that there will be continued demand for occupational therapy services.

There are other trends that influence occupational therapy


services for children with autism. For example, children with
autism are increasingly being integrated into inclusive settings,
occupational therapy practice is shifting towards a consultative
model, and there is an increased demand for cost-effective
interventions (Baranek, 2002; Simpson, 2005). Consequently,
occupational therapists are increasingly challenged to provide
effective intervention recommendations that 1) enable a child
to function within inclusive settings, 2) are cost-effective, and 3)
can be implemented by a variety of caregivers.
Occupational therapists intervene most frequently in the
area of sensory dysfunction with children with autism (Case-

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Smith & Miller, 1999; Watling, Deitz, Kanny & McLaughlin,
1999). Sensory dysfunction is based on the assumption that
aberrant behaviours reflect the central nervous system's
(CNS) inability to integrate incoming sensory information
and modulate arousal (Baranek, 2002). In terms of arousal, a
child may be described as overaroused (the child responds
more to stimulation from his or her environment than other
children), or underaroused (the child responds less to stimulation from his or her environment than other children)
(Rogers & Ozonoff, 2005). A child may also fluctuate between
these two states of arousal (Schneck, 2001).
Occupational therapists often recommend sensory stimulation as a way to address sensory dysfunction within inclusive settings. Sensory stimulation involves applying one type
of sensation, such as deep pressure, directly to a person with
the purpose of eliciting a behavioural response (Bundy &
Murray, 2002). Somatosensory stimulation is a specific subtype of sensory stimulation that focuses on tactile, vibratory,
or proprioceptive input. Examples of somatosensory stimulation interventions include massage, joint compressions,
brushing or rubbing parts of the body, pressure garments,
and weighted items such as vests or blankets.
Some of the more commonly expected clinical outcomes
of sensory stimulation interventions, including somatosensory stimulation, are improved arousal modulation,
decreased sensory defensiveness, increased socialisation,
decreased self-stimulatory behaviours, and decreased anxiety
(Case-Smith & Miller, 1999; Schneck, 2001). Somatosensory
stimulation interventions are frequently recommended in
home and school settings by occupational therapists
(Watling et al., 1999), perhaps because of the ease with which
they can be easily integrated into an inclusive setting without
disrupting other children.
Sensory stimulation intervention is frequently confused
with sensory integration treatment both within and outside
of the occupational therapy profession (Anzalone & Murray,
2002). Sensory integration treatment is based on meaningful,
self-directed, adaptive interactions (Bundy & Murray, 2002),
while sensory stimulation intervention may involve the child
as a passive recipient of stimulation, and intervention does
not have to be provided in the context of meaningful occupation. Therefore, although sensory stimulation strategies
may be incorporated into sensory integration treatment,
these terms are not synonymous. However, the use of sensory
stimulation interventions may be based on sensory integration theory. Advocates of sensory integration theory suggest
that sensory stimulation broadly improves the CNS's ability
to organise and process sensory information to allow for
better adaptive responses. Case-Smith and Bryan (1999)
postulate that the provision of controlled sensory stimulation
enables a child to "modulate incoming sensory information
and achieve homeostasis, so he or she is able to focus on
relevant stimuli, assimilate incoming sensory information,
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and respond in developmentally appropriate ways" (p. 490).


Proponents of massage therapy suggest that somatosensory
stimulation affects positive outcomes, such as increased
attention to task, due to enhanced parasympathetic activity
(Escalona, Field, Singer-Strunck, Cullen & Hartshorn, 2001;
Field et al., 1997), which represents a response at the level of
the autonomic nervous system. In actuality, the underlying
neurological basis for sensory dysfunction and anticipated
outcomes of sensory stimulation are not yet understood
(Baranek, 2002).
Regardless of our understanding of underlying mechanisms, interventions that include sensory stimulation are the
most common occupational therapy recommendation for
children with autism (Case-Smith & Miller, 1999; Watling et
al., 1999). However, occupational therapists report that they
do not have a clear rationale for sensory-based interventions,
and that guidelines for implementing these interventions are
lacking (Olson & Moulton, 2004). The purpose of this paper
is to provide occupational therapists and others with a better
understanding of somatosensory stimulation interventions
for children with autism by evaluating and summarising the
current state of research in this area. This review focused
specifically on somatosensory stimulation interventions feasible within inclusive settings.

Methods
Searches were conducted using MEDLINE, CINAHL,
PsychINFO, and OTDBase. Intervention studies specific to
children with autism spectrum disorder and published in
English language peer-reviewed journals between 1985 and
2005 were examined. Subject headings and keywords
included general terms related to occupational therapy intervention (occupational therapy, intervention, effectiveness,
evidence-based practice); diagnostic terms (autism, autism
spectrum disorder, pervasive developmental disorder); and
terms broadly related to somatosensory stimulation interventions (sensory integration, sensory modulation, sensory
processing, sensory stimulation, habituation, arousal, attention, touch, pressure). Unpublished Master's theses and conference proceedings were not included in this review, as they
are not accessible to the general public. Studies that addressed
somatosensory stimulation not feasible within the context of
daily activity and not typically available to therapists or
clients (e.g., Grandin's hug machine) were also excluded. A
total of six published studies meeting the inclusion criteria
were found that addressed the effectiveness of somatosensory
stimulation interventions feasible within an inclusive setting.
Table 1 provides a comparative summary of the studies. This
review was not systematic in nature. Articles were reviewed
and synthesized based on the manuscript critique process
outlined in Seals and Tanaka (2000). Our aim was to provide
practicing clinicians with an understandable qualitative
assessment of the current literature in this area.

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(1992) reported that the use of pressure garments resulted in
decreased negative behaviours for an 8-year-old girl with
autism, severe developmental delay, and possible seizure disorder.
Although many positive outcomes were reported, the
results provided by these studies must be interpreted with
caution given design limitations. Case studies do not enable
the researcher to control for potential confounders such as
investigator bias, maturation, changing medications, and cooccurring treatments. This lack of control significantly limits
confidence in the findings.
Two studies (Larrington, 1987; McClure & Holtz-Yotz,
1991) used numerous interventions simultaneously, and
Larrington included numerous outcomes, making specific
conclusions difficult. Furthermore, results may not be generalisable to younger children with autism, since two of the
three case studies focused on adolescents and all three of the
participants were dually diagnosed. Moreover, one has to ask

Results
Case studies
Case studies are commonly used to introduce new interventions or techniques by exploring individual responses.
Indeed, the first three published studies that reported the
effects of somatosensory stimulation interventions for children with autism were case studies. Larrington (1987)
reported numerous positive responses to a variety of sensory
inputs including some somatosensory stimulation (e.g.,
weighted vests, vibration) for a 15-year-old boy with autism
and severe mental retardation, who had a long-standing
history of destructive behaviours. McClure and Holtz-Yotz
(1991) described decreases in self-stimulatory and self-injurious behaviours, and increases in social interaction and
attention span as a result of pressure and tactile input
provided through bilateral, foam arm splints for a 13-year old
boy with autism and severe mental retardation. Zissermann

TABLE 1
Summary of somatosensory stimulation intervention studies for children with autism
Citation

Age

Design

Intervention

Outcomes Measured

Reported findings

Escalona et al.
(2001)

x = 5.2 yrs

RCT with
alternative
treatment

20

Touch (massage)
therapy vs. reading
attention control
group

On-task behaviour,
stereotypical
behaviour, social
relatedness, sleep
diaries

Massage group demonstrated


more on-task behaviour, less
stereotypic behaviour,
increased social relatedness,
fewer sleep problems

Field et al.
(1997)

x = 4.5 yrs

RCT with
alternative
treatment

22

Touch (massage)
therapy vs. touch
control group (hold
in lap and play
game)

Off-task behaviour,
touch aversion,
withdrawal

Off-task behaviour and touch


aversion decreased in both
groups; orienting to irrelevant
sounds and stereotypic
behaviours decreased in both
groups, but significantly more
in touch therapy group

Fertel-Daly et al.
(2001)

2-4 yrs

ABA singlesubject
design

Weighted vest

Attention to task,
number of
distractions, selfstimulatory behaviours

Decreased in number of
distractions, increase in
attention to task, decrease in
self-stimulatory behaviours

Larrington (1987) 15 yrs

Case report

Multi-sensory input
including weighted
vest, vibration and
oral stimulation

Variety of outcomes:
alertness, attention,
play skills, self-abuse,
destructive behaviour

Positive outcomes for many


outcomes including decreased
destructive behaviour and
self-injury, increased
social interaction and play
skills

McClure
& Holtz-Yotz
(1991)

Case report

Elbow splints;
followed by elastic
arms wrappings

Self-injurious
behaviour

Decrease self-injurious
behaviour and selfstimulations; increased social
interaction with elastic
bandages

Case report

Pressure gloves
and vest

Self-stimulatory
(hand-hitting)
behaviours

Decrease in self-stimulatory
behaviour with vest

13 yrs

Zisserman (1992) 8 yrs

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if the participants in these case studies would be considered
autistic by today's diagnostic standards, since much has
changed with respect to the diagnosis of autism since these
studies were published (e.g., Autism Diagnostic Observation
Scale, Lord et al., 2000; Autism Diagnostic Interview, Lord,
Rutter, & Le Couteur, 1994).
Although the strength of the research is significantly limited, these case studies do provide an interesting introduction
into the rationale for clinical interventions. For example,
McClure and Holtz-Yotz (1991) originally recommended
splints to physically inhibit self-injurious behaviours. They
discovered that when the splints were no longer available, the
participant would attempt to wrap his arms with towels or
bedding. Concurrently, self-stimulatory, self-injurious, and
aggressive behaviours toward others increased. Thus, the
authors hypothesised that the deep pressure and tactile input
provided by the splints and arm wrappings calmed the child
by acting as a substitute for the self-injurious and self-stimulatory behaviours. Zissermann (1992) reported on a child for
whom firm hugs and back rubs decreased behavioural problems (e.g., hitting a table) and increased calmness. She
hypothesised that wearing tight-fitting gloves or a vest would
have the same results, while allowing the child to participate
in functional activities. Larrington's rationale differed significantly, however, as she approached assessment and intervention from a traditional sensory integration philosophy.

Single-subject research
Fertel-Daly, Bedell, and Hinojosa (2001) explored the effects
of using a weighted vest to address classroom behaviours for
four preschool-aged children with pervasive developmental
disorder (not specified) and one child with autism.
Measurements were taken of the number of distractions, the
length of focused attention to task, and the duration and type
of self-stimulatory behaviours during a table-top, fine motor
activity. One-pound weighted vests were determined effective
in decreasing the number of distractions, increasing attention to task, and decreasing the duration of self-stimulatory
behaviours in four out of five participants.
The authors chose an ABA single-subject design for their
study, which enables systematic evaluation of behaviours
while allowing for individual variations. The ABA design is
considered more rigorous than case studies (or AB designs)
because it adds increased control through replication of the
baseline phase. However, an ABAB design would have further
strengthened the results by providing increased control
through replication of both the baseline and intervention.
The authors reported that this design was not possible due to
time constraints.
The visual results were presented clearly, however, no
statistical interpretation was used to support the visual interpretation of the graphs (e.g., two standard deviation
approach; Barlow & Hersen, 1988). Of most concern, how396

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ever, is that only one rater was used during the intervention
and return-to-baseline phases. Therefore, rater bias and
observer drift may have influenced the results. Given that the
rater was the first author and, therefore, not blinded to intervention condition or to the expected outcomes of the study,
this concern is noteworthy. The authors did take care that the
time of day for data collection remained consistent for each
child, thus controlling for systematic behaviour fluctuations
during the day. Generalisability was also greatly enhanced, as
the study was conducted in the participants' natural
preschool environment. This study does provide important
preliminary support for an intervention strategy reported to
be used by 82% of occupational therapists who work with
children with autism (Olson & Moulton, 2004).

Group comparison designs


Field and colleagues (1997) investigated the effects of massage therapy for preschool children with autism. Twenty-two
children were randomly assigned to receive either two 15minute massage sessions per week for four weeks (experimental condition) or two 15-minute play sessions per week
for four weeks (control condition). During the play sessions,
the child sat on the research assistant's lap and played a
game. Classroom observations of touch aversion, off-task
behaviour, orienting to irrelevant sounds, and stereotypical
behaviours were conducted on the first and last days of the
study. Touch aversion and off-task behaviours decreased in
both groups. Orienting to irrelevant sounds and stereotypical
behaviours decreased in both groups, but significantly more
in the massage therapy group. The authors point out that the
decreases in both groups are not surprising given that both
interventions provided additional one-on-one time and
physical contact with an adult.
Escalona and colleagues (2001) hypothesised that positive
results reported in the treatment group in the previous study
(Field et al., 1997) would be improved upon with more frequent massages by a familiar person. Therefore, in their own
study, twenty children with autism were randomly assigned to
either receive a 15-minute massage (experimental condition)
or be read a Dr. Seuss story for 15-minutes (control condition).
Both conditions were implemented at bedtime by the child's
parent for one month. Groups were stratified to ensure group
equivalence based on IQ, speech and language assessment
scores, and adaptive functioning. The effects of massage therapy on behavioural outcomes including hyperactivity, on-task
behaviour, stereotypical behaviours, and sleep problems were
investigated. The effects of the intervention were assessed
through sleep diaries (kept by the parents) and observations
(made by teachers and research assistants) at school.
Improvements were noted for all targeted behaviours for the
treatment group. However, it must be noted that the data from
the sleep diaries may have been biased since parents were not
blinded to the intervention condition.

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For both of these studies, confidence in the results was
increased by random assignment to groups, teachers and
research assistants blinded to group assignment, and equivalent baselines between groups. This stratification (combined
with the small age range) helped to control for the heterogeneity inherent in the diagnosis of autism. However, the ratio of
males to females in the study by Field and colleagues (1997)
was 12:10 and the study by Escalona and colleagues (2001) was
12:8, which is not representative of the widely accepted ratio of
approximately 4:1 (Fombonne, 2003). Although these ratios
(12:10 and 12:8) may have occurred by chance, one has to
wonder how representative these two samples were of all
young children with autism. Also, the natural settings in these
studies enhance the generalisability of the results. This generalisability is especially true in the study by Escalona and
colleagues (2001), where the intervention took place in the
privacy of the child's home at no cost to the family with positive results noted both at home (sleep diaries) and school.
Although many positive results were reported, their
interpretation is difficult given that the targeted behaviours
were not operationally defined. In the absence of any clear
understanding of how the variables were measured, it
becomes difficult to evaluate the mean change scores, which
tended to be small and comparable between groups. In addition, the papers do not distinguish between statistically and
clinically significant differences.
Both studies would have been strengthened by providing
standard deviations and confidence intervals as part of the
results. Inclusion of these measures would have allowed other
researchers to calculate effect sizes and estimate the clinical
significance, thereby gaining insight into whether repeated
nightly massage with a primary caregiver resulted in a larger
effect than massage given twice weekly by a researcher. The
Bonferroni correction reported by both Field and colleagues
(1997) and Escalona and colleagues (2001) is meant to
correct the alpha level to be more conservative that the typically accepted 0.05 level, controlling for type 1 error when
multiple comparisons are made. However, given that the
authors reported the results at the 0.05 level, it is difficult to
know whether results reported as significant did indeed
include this correction.

There have been three more rigorous studies investigating the effectiveness of various somatosensory stimulation
interventions for children with autism including one singlesubject ABA design (Fertel-Daly et al., 2001) and two randomised controlled trials (Escalona et al., 2001; Field et al.,
1997). The clinician can be more confident in the results suggested by these studies, since they offer more control over
extraneous variables. However, generalisability may still be
limited due to small sample size and a lack of detail provided
about the participants.

Discussion
Variability of interventions
Of the six studies published that relate to somatosensory
stimulation interventions for children with autism, two
investigate the effects of massage therapy, one investigates the
effects of weighted vests, one investigates the effects of a pressure vest and gloves, one investigates the effects of arm splints
and pressure arm wrappings, and one investigates a variety of
sensory stimulation. Can we really compare between all of
these interventions? Although these interventions are based
on the same general assumption that providing somatosensory stimulation will have a calming or organizing effect on
the nervous system, none of these studies address this underlying assumption. We need to test the underlying theorysomatosensory stimulation induces physiological effects on
the nervous system-to see if effects are similar with various
types of somatosensory stimulation. Similar effects with
different types of stimulation can increase one's confidence
that individualised interventions may be effective. In addition, we need to replicate studies that address behavioural
and functional outcomes of commonly used somatosensory
stimulation (e.g., weighted vests) to increase our confidence
that specific interventions are effective.

Variability of outcomes
We were surprised by the variability of outcomes expected
from the interventions used. Can we reasonably expect
somatosensory stimulation interventions to influence all of
these outcomes? Are the outcomes used conceptually congruent with the interventions? In theory, different behaviours are
improved if somatosensory stimulation affects the nervous
system; however, we need to better define our outcomes, both
in research and in clinical practice, to determine if our interventions are truly effective. In the literature and in our own
clinical experience, broad goal statements such as "improved
sensory modulation" are not uncommon. However, what
does this mean? Will a parent or teacher of a child with autism
feel comfortable spending time, money, and energy on an
intervention that will improve sensory modulation? We suggest that a parent or a teacher would be more satisfied if outcomes were specific, for example, increased time on task in the
classroom or decreased self-hitting behaviour. Claims of

Summary of available research


Half of the existing research related to autism and
somatosensory stimulation is in the form of descriptive case
studies (Larrington, 1987; McClure & Holtz-Yotz, 1990;
Zisserman, 1991). Although these designs have high face
validity for the practicing clinician, they are known to be
weak study designs (Barlow & Hersen, 1988) since they offer
little to no control of extraneous variables (e.g., co-occurring
treatments, maturation, investigator bias). Therefore, the
clinician cannot be confident that the results actually represent the effects of the intervention.
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intervention effectiveness are strengthened with replication of
research with different participants, in different settings, and
by different researchers. Therefore, replication of specific outcomes from previous studies, with increased control where
warranted, may be a promising area for future sensory stimulation intervention research.

Variability of autism
Empirical research related to intervention effectiveness is also
difficult because autism is comprised of an extremely heterogeneous spectrum of disorders. The course of autism varies
significantly between individuals and within an individual.
For example, a child may seek sensory input one day, then be
sensitive to sensory input the next (Schneck, 2001).
Therefore, it is difficult to determine the effectiveness of an
intervention because it may appear effective for some individuals and ineffective for others, or it may appear effective
for one child one day and ineffective for the same child the
next day. This variability was addressed, in part, by Field and
colleagues (1997) and Escalona and colleagues (2001), who
controlled for intelligence quotient and other factors. Future
research also needs to control for variability in autism in
group designs, or provide detailed documentation of individual profiles in single-subject research. Although limiting
participants initially decreases the generalisability of results,
rigorous replication with various subgroups will strengthen
the confidence that researchers, funders, families, and clinicians can have in recommended interventions.

Best practice: the need for


rigorous research
Many factors can affect the perceived or real level of functioning of a child when evaluating the effectiveness of an
intervention. Awareness of potential biases and confounders
becomes increasingly important when an intervention does
not have a strong base of empirical support. The difficulty
lies in deciphering the contributions of the intervention from
other contributing variables. For example, did the child
receive extra attention from a teacher or therapist coinciding
with the implementation of the intervention? Is the therapist
biased towards interpreting behaviours based on assumptions of sensory processing dysfunction? Did the child
mature over time, take new medications, or receive some
other intervention at the same time? Appropriate controls
and methods are needed to address alternative explanations
so clinicians, caregivers, and children do not spend emotional
or financial resources, or their already limited time on ineffective interventions, especially when other interventions do
exist that have empirical support (Baranek, 2002).
Referring to the lack of empirical research on these interventions, Goldstein (2000) stated:
Perhaps more than any other area in the behavioural sciences, the field of autism research should have taught us
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a strong form of a popular maxim: 'If it is too good to be


true, it is too good to be true' (p. 423).
Researchers open the door to criticism by using less rigorous study designs and analysis. Although it is recognized
that all research has humble beginnings, such as anecdotal
reports or descriptive case studies (Johnson & Danhauer,
2002), it is time for occupational therapy intervention
research to move beyond weak designs. We do not mean that
all research should incorporate randomised controlled trials.
That is neither feasible nor warranted at this stage. Singlesubject research that enables each child to serve as his or her
own control may be the most appropriate design given that
we often treat each child individually. Single-subject research
is not meant to demonstrate generalisable outcomes, but can
provide preliminary evidence to support a clinical hypothesis
and can help guide future research the design that best
matches the question should be used (Bartlett et al., 2005).
More rigorous study designs will enable clinicians to feel
more confident in their intervention recommendations, and
will make clients, caregivers, and third party payers more
confident that they have not wasted valuable energy, time,
and resources. Most importantly, more rigorous research in
this area will allow us to be more effective in helping the children who need it most.
It does appear that research related to somatosensory
stimulation for children with autism has become more rigorous over the past decade. One can feel more confident that the
results of the three most recently published studies represent
a true effect related to the somatosensory stimulation intervention due to increased control over potential confounders.
However, it is still of concern that the interventions most
commonly recommended by occupational therapists for children with autism are only supported by six studies, three of
which are case studies and none of which are replications.

Implications for occupational therapy


Occupational therapists must be concerned by the evidence
on which interventions are based. As demonstrated here,
much of the literature on somatosensory interventions for
children with autism has significant limitations. Although it
appears that somatosensory stimulation (specifically that
which provides deep pressure input) may have positive
behavioural outcomes, there is not enough evidence to specify that these outcomes are based on our theoretical premise
of affecting underlying mechanisms. However, occupational
therapists can take some comfort that the rigor of research in
this area seems to be improving.
It is important to recognize that a lack of empirical evidence supporting the effectiveness of an intervention may
not be synonymous to ineffective interventions; rather, effectiveness may not yet have been empirically examined
(Baranek, 2002; Miller, 2003). However, ineffective interventions become harmful when they replace effective interven-

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Acknowledgements

tions and when they mislead caregivers into believing that


their effectiveness is established (Gresham, BeebeFrankenberger & MacMillan, 1999; Simpson, 2005).
Occupational therapists incorporate clinical observation
and experience into intervention recommendations.
However, clinicians must also provide an empirical rationale
for their recommendations, especially when financial,
human, and emotional resources are expended. "For a procedure with no evidence of efficacy to be used on the public
with claims of success, to charge money for these services,
and to train practitioners in this model borders on unethical
behaviour" (Shaw, 2002, p. 1). The use of empirical data to
support clinical recommendations promises to enhance the
reputation of both the individual clinician and the entire
profession.
Until we have a strong base of empirical support, there
are steps occupational therapists can take that should
increase the confidence with which they can intervene. Ten
recommendations for practicing clinicians are provided in
Appendix 1. In addition, clinicians can add valuable data to
the research literature by collecting well-controlled, consistent data on their clients, including the influence of possible
extraneous variables that may affect a child's performance.
Best-practice guidelines recommend that clinicians
always take baseline measures before intervention begins
(Canadian Association of Occupational Therapists, 1996).
Taking repeated baseline-intervention measurements can
be relatively simple. As long as it is ethical, removing
intervention for a short time to measure if treatment effects
subside or remain also provides support to either continue or
discontinue an intervention. By taking small measures such
as these, one can only improve his or her credibility and
reputation as an ethical, responsible clinician. In addition,
communication with others and dissemination of findings
can strengthen occupational therapy intervention research.

This work is supported by a SickKids Foundation, Children


and Youth Home Care Network, Doctoral Award (HC 06311), and the Canadian Institutes of Health Research, Autism
Research Training Program received by the first author. The
authors would like to thank Dr. Joyce Magill-Evans for
reviewing an earlier draft of this paper.

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Conclusion
Sensory-based interventions, including somatosensory
stimulation, are the most common occupational therapy
recommendation for children with autism. The results of this
review indicate that research investigating the effectiveness of
somatosensory stimulation interventions for children with
autism has become more rigorous over time; however, studies are still few in number and replication is limited.
Although these interventions appear promising, it is still difficult for clinicians to recommend interventions with confidence. Researchers and clinicians are therefore challenged to
systematically investigate the effects of sensory stimulation
interventions for children with autism. Building our knowledge will enable occupational therapists to contribute to
autism intervention and enhance the lives of children with
autism and their families.

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Appendix 1
The following list provides clinical considerations for intervention in an area in which empirical support is limited.
Some of these considerations have been adapted from
Baranek (2002) and Gresham et al. (1999).
1. Have a healthy skepticism of intervention strategies
based only on subjective data and anecdotal evidence.
2. Have a healthy skepticism of any interventions whose
authors or advocates are defensive when their program is
honestly criticized.
3. Obtain baseline data prior to starting any intervention.
4. Control for as many variables as possible when trying to
determine if an intervention is effective. For example, do
not try to measure the success of a new intervention at a
time when the child attends a new school, works with a
new teacher, or becomes ill.
5. Provide interventions in shorter, monitored increments
(e.g., one to three months), documenting progress in a
systematic manner.
6. Be very clear in your rationale for recommending a specific intervention. For example, is a weighted vest recommended to address attention to task, or simply because
they are frequently recommended for children with
autism?
7. Recognize that some new interventions may ultimately
be effective, but have not yet been empirically validated.
8. Remember that sensory stimulation intervention strategies are only one of several options.
9. Remember there is no cure for autism. Not every intervention will work for every child.
10. Be honest with clients and caregivers. Until evidence is
available, it is unethical to declare an intervention has
been proven to work.

Authors
Sandra Hodgetts, MClSc, OT is a Doctoral Candidate,
Faculty of Rehabilitation Medicine, University of Alberta,
2-64 Corbett Hall, Edmonton, Alberta, Canada T6G 2G4.
Tel: (780) 492-8568. E-mail: sandra.hodgetts@ualberta.ca
William Hodgetts, MSc is a Doctoral Candidate, Faculty of
Rehabilitation Medicine, Assistant Professor, Department
of Speech Pathology and Audiology, Faculty of
Rehabilitation Medicine, University of Alberta, 2-16
Corbett Hall, Edmonton, Alberta, Canada, T6G 2G4

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